Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.64(a) | The bedroom floor has a sticky substance and has not been mopped. | Clean and sanitary conditions shall be maintained in the home. | On 12/21/2024, the bedroom floor was unclean. The residential manager and staff mopped the floor, making it clean and sanitary. |
12/21/2024
| Implemented |
6400.66 | There was no light in the bedroom for individual #2. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| 12/21/2024: The agency's maintenance team installed light in the individual's #2 bedroom to ensure his safety and avoid any potential accidents.
In the future, the Site Manager, House Lead, and Maintenance Personnel will conduct checks to ensure that all appliances, including lights, are adequate in the home and individual #2's bedroom, ensuring full compliance with ODP regulations. |
12/21/2024
| Implemented |
6400.68(b) | The water temperature in the bathroom was at 129 degrees Fahrenheit. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | On December 30, 2024, the COO of Halia and the maintenance personnel at the apartment complex adjusted the water temperature in the bathtubs and kitchen areas to a compliant level of 120°F. Staff will continue to assist residents in regulating the water temperature as needed. |
12/30/2024
| Implemented |
6400.110(a) | The smoke detector did not work. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | On January 5, 2025, the COO of Halia supervised the maintenance personnel at the apartment complex to address the issue with the smoke detector, and it is now in working condition. |
01/05/2025
| Implemented |
6400.32(i) | Clothes for individual #2 were locked in another room. The individual's behavior support plan does not contain a restrictive component to include restricted access to clothing. | An individual has the right of access to and security of the individual's possessions. | Through the agency's residential manager, the clothes of Individual #2 were returned to his bedroom. It is important to note that keeping individual #2's clothes in another bedroom was not intended to restrict access to them; rather, it was done to give the individual more space to safely and orderly store individual #2's clothes. |
12/20/2024
| Implemented |
6400.32(n) | There was no evidence of the right to be free from abuse form, provided by the supports coordinator, being retained and accessible at the home for individual #2. This form provides individual specific non-agency team contact information for individuals to contact someone if they feel they are being mistreated. | An individual has the right to unrestricted and private access to telecommunications. | Some support coordinators regrettably failed to provide individuals with information about their right to be free from abuse. To address this concern, on December 28, 2024, we produced multiple copies of the relevant materials, completed them, and displayed them prominently in all of our homes for easy access by those in our care. These materials include specific non-agency team contact details, enabling individuals to seek help if they feel mistreated. |
12/28/2024
| Implemented |
6400.163(a) | Erythromycin eye ointment prescribed for individual #2 was not in the original prescription container and there was no prescription label. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | On December 21, 2024, our agency nurse, under the supervision of the Chief Operations Officer (COO), ordered Erythromycin eye ointment, ensuring it was in its original prescription container. |
12/21/2024
| Implemented |
6400.182(c) | The individual plan (ISP) has not been updated to reflect Individual #2's current behavioral support plan. The individual has a non-restrictive behavior support plan dated 8/31/24. A copy of the plan was provided by the provider. However, the ISP lists an old plan that includes details of a token economy, which would be a restrictive intervention. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The program specialist at Halia printed an updated ISP for individual #2. |
12/21/2024
| Implemented |
6400.192 | There were no written restrictive procedures or policy for the locking of individual #2's clothing in second unused bedroom. The staff on duty were unaware when questioned that this was a restrictive procedure. | The home shall develop and implement a written policy that defines the prohibition or use of specific types of restrictive procedures, describes the circumstances in which restrictive procedures may be used, the staff persons who may authorize the use of restrictive procedures and a mechanism to monitor and control the use of restrictive procedures. | The current situation regarding the procedures for locking Individual #2's clothing in the second bedroom indicates that such measures are unnecessary. The individual has exclusive access to his clothing without any interruptions. However, staff will proceed with transferring Individual #2's clothes to his bedroom. The team has decided not to impose any restrictions on access for the individual currently. |
06/20/2025
| Implemented |